Barmer Registration Over 30

121.56

€

from 154.97

€

I. Private Medicine info

Please answer,to the best of your knowledge, all the below health questions.

Height in centimetres (cm) ^*

Body weight in kilograms (kg)^*

1. Have you ever been detected with a HIV infection? ^*

Yes

2. Have you ever had any complaints,illnesses,health problems,or consequences of accidents in the last 5 years? ^* Hint excluding preventive check-ups without findings, colds, flu-like infections and short-term gastrointestinal infections

Yes

3. Have you been treated by doctors,dentists,psychologists or psychotherapist as an outpatient or inpatient in the last 3 years and what treatment has been recommended? ^* Hint Please do not indicate any medical check-ups where no findings were made.

Yes

4. Have you taken any medication (other than contraceptives) over a period of more than 14 days in the last 12 months? ^*

Yes

5. Do you have any missing teeth that have not yet been replaced? ^* Hint If yes, please state the number (full gap closure, wisdom teeth and deciduous teeth are not considered missing teeth). If none are missing, please enter 0. Number of missing teeth ^*

II. General info

Application for non-insurability via statutory health insurance BARMER

Starting from (Begin of the semester) ^*

Personal info ^*

Male

Female

Diverse

Undefined

Given names ^*

Surname ^*

Date of Birth ^*

Street, Street Nr. ^*

Country^*

Post code, city ^*

Maiden name ^*

Place of Birth ^*

Country of Birth ^*

Nationality ^*

E-Mail ^*

I was last insured or lived abroad

Name of country ^*

FREE Incoming Insurance (Travel Insurance)

Arrival Date in Germany ^*

Insurance period ^*

180 days

Passport ^*

Admission for the university/ Employment contract ^*

Personal photo ^*

I consent to having this site collect my personal data and agree, that I would be contacted by telephone or e-Mail. More about Data Protection at: Data Protection

Yes, I would like to register as a member of the insurance at Barmer.

Signature ^*

Clear

Confirm Signature

Notice: Please confirm your signature before submitting form